Shortage of donor organs is one of the major barriers to transplantation worldwide, especially, in countries where cadaveric organ donation is yet limited. If the minimum criteria of HLA typing and strict donor evaluation process to eliminate the comer­cially-based donation were fulfilled, the transplant outcome of unrelated donation would be a viable option comparable to one­haplotype mismatched living related kidney transplantation.[1],[2]

Donor exchange program (SWAP) was attempted as an alternative way to alleviate the organ shortage in Korea. Genetically related living renal transplantation was not always possible because of positive lymp­hocyte cross-match, incompatible blood type ABO, and poor HLA matching. In this situation, we exchanged the donors between families with the same situation.

The first SWAP between two families in Korea was successfully performed in 1991, and at our institution in 1995. There was no difference in patient and graft survival rates between recipients from swap donors and patients from other kinds of living donors. After the success of direct swap donor program, we developed the second stage of donor swap (SWAP-around) program to expand the donor pool by enrolling a pool of close relatives, spouses, friends of recipients and emotionally motivated voluntary donors after strict donor evaluation, and exchanged the donors with one another within this donor pool. Minimum acceptance criteria for HLA matching has been A+B=>2, or DR=>1 antigen. We already reported the encouraging results from three-center colla­borative study in Transplantation in 1999.[3]

Since 1995, we have performed 80 cases of SWAP living donor renal transplantations. The numbers (and as percentage of total living donor transplant) of swap recipients were 2 (1.5%) in 1995, 28 (25.5%) in 1999, and 14 (14.3%) in 2001. Five year patient and graft survival were 92.1 and 90.6%, respec­tively in swap recipients, 94.3 and 90.0%, respectively in other kinds of unrelated recipients, and 94.5 and 90.7%, respectively in HLA one-haplotype mismatched related recipients during the same period.

In conclusion, we could achieve some success in reducing the shortage in donor supply with SWAP and SWAP-around program in addition to doing other kinds of unrelated donor programs without jeopardizing excellent graft survival. Potentially exchan­geable donors should undergo careful and strict medical evaluation by doctors and social evaluation by social workers and coordinators as a pre-requisite for kidney donation. Expanding SWAP-around program to a regional or national pool could be an option to reduce the organ shortage in the future.